Introduction
This booklet is written to provide information for people under care at Blackpool Teaching Hospitals and their relatives.
Although it is not possible to include everything you may need to know, your doctor or nurse will be able to answer specific questions which you may have.
Some of the treatment you require will need to be given directly into your bloodstream. To do this, we will place a device into your vein, called a venous access device. This enables us to have access to your venous system to give your treatment.
There are several different types of devices available. One type is called a peripheral cannula. It is a small plastic tube that is inserted into a vein in your lower arm or hand, through a needle. This needle is then removed, leaving the cannula in place for a few hours or up to several days while you have treatment. We will remove the cannula when you finish your treatment and you will be given a new cannula every time you need treatment. Sometimes, this can affect the veins and make it harder to insert the cannula. To help prevent this from happening you can have a central venous access device put in instead.
Some treatment drugs cannot be given into the veins of the hand or the arm and can only be given through a central venous access device, into a larger vein leading to your heart. This may be required if you need to have chemotherapy via a pump.
What is a central venous access device (CVAD)?
A central venous access device (CVAD) is made of a non-irritant material, for example, silicone or polyurethane, which means it can be left in for as long as clinically indicated (several weeks or months, or even longer). The CVAD may contain one or two tubes. A CVAD containing two tubes is called a double or dual lumen catheter.
What are the advantages of having a CVAD?
All types of CVAD can be used to give you fluids and drugs and they may also be used to take blood samples. The CVAD will prevent you from having repeated needle pricks from blood taking or insertion of cannulas during treatment.
What types of CVADs are available?
There are three main types of CVAD
1. A peripherally inserted central catheter (PICC)
2. A skin-tunnelled catheter or Hickman line
3. An implanted port (chest or arm)
Are there any risks involved in the insertion of a CVAD?
Occasionally there can be complications when inserting a CVAD
• During insertion of a chest port or skin-tunnelled catheter, the needle or guide wire can puncture the top of your lung causing an air pocket (pneumothorax) or a pocket of blood (haemothorax). This happens very rarely and you would probably be unaware of this but you may become slightly breathless. A chest x-ray is taken after the catheter has been inserted to check that it is correctly positioned and to check to see whether there is a pneumothorax. If there is one, it can be treated straight away usually with a chest drain. Once treated, a pneumothorax or haemothorax will not cause any long-term problems.
• The PICC may not thread into the correct position and the tip may not be in the correct vein.
• Sometimes there may be bruising at the site where the needle went into your vein, or there might be damage to an artery or nerve (about one in a 1000 chance).
• If an artery is damaged it could cause bleeding where we may have to get surgeons involved to stop the bleeding or give you a blood transfusion. This is extremely rare and your nurse or doctor will advise if this risk is higher for you. The risk of bleeding is higer in a skin-tunnelled catheter and a chest port. If you take anticoagulants you will be asked to stopped these prior to your procedure.
Are there any risks once the CVAD has been inserted?
• There is a risk of infection. The risk is usually between one and three in 100 but can be higher depending on many other factors, such as your diagnosis or treatment. Your doctor or nurse will explain the risk to you. You may be able to have antibiotics to treat the infection if it is local around the CVAD site. If not, the CVAD may need to be removed.
• Once the CVAD is in place, there is a risk of a clot (thrombosis) forming around the catheter. This occurs in less than three of every 100 cases depending on your diagnosis, treatment or if you have had a clot before. Your doctor or nurse will explain the risk to you. You may need to take blood thinning (anticoagulant) medication and the CVAD may need to be removed if the blood clot does not respond to the medication.
• The CVAD may become blocked. This can usually be unblocked by the nursing staff, however, if it cannot be unblocked, the CVAD will have to be removed.
• The CVAD may split or become damaged.
• The CVAD may become dislodged and if no longer in the correct position, it will need to be removed.
How will I know which device to choose?
You may be able to choose from any of the three main types of CVADs; however, your choice will depend on the type of therapy you are going to have, duration of therapy and your physical condition.
Your choice maybe limited, for example, if you have no suitable veins in your arms or you have had lymph nodes removed during breast surgery.
For a skin-tunnelled catheter or a chest port you will be required to lay flat on one pillow for up to 45 minutes. If this is a difficult then a PICC or PICC port will be a better alternative as we can position you slightly head up.
Even if you have no choice about the type of device, you may be able to discuss how and where the device will be placed with the team. We will consider your choice of which side you would prefer for the device to be inserted but this could change on the day due to clinical reasons.
The table on the following page summarises the main features of the three different types of CVADs. More detailed information about each individual type follows afterwards. You should discuss your choice of device with your nurse, as other hospitals may offer different ways of inserting the devices.
| Peripherally Inserted Central Catheter (PICC) | Skin - tunnelled catheter (Hickman Line) | Implanted port (chest port or arm port) | |
| Do I need an anaesthetic for insertion? | Local anaesthetic will be used | Local anaesthetic will be used | Local anaesthetic will be used |
| Will it leave any scars when inserted or removed? | No. Minimal puncture scar | Yes. There may be 2-3 small scars | Yes. There will be one scar about 2.5cm long above where the port is and one small puncture scar in the neck |
| Can I bath and shower with it in? | Yes, you can shower but you must wear a protective sleeve over your arm. We recommend that you do not take a bath. | Yes, you can shower, but you must make sure you have a waterproof dressing over your chest. We recommend you do not take a bath. | Yes |
| Can I swim with it in? | No | No | Yes |
| Will I still need to have needles inserted for my treatment | No | No | Yes. A small, specialised needle is used to access the port through the skin |
| Do I need to have the dressing changed | Yes Once a week | Yes. Once a week | No |
| Does it need to be flushed to keep it working | Yes. Once a week | Yes. Once a week | Yes. Once every eight weeks |
| Do I need an anaesthetic for the removal | No | Yes. Local anaesthetic | Yes. Local anaesthetic |
What is a PICC?
A peripherally inserted central catheter (PICC) is a tube which is inserted into a vein in the top of your arm, above the bend of the elbow. It is moved up into the large vein leading to your heart. A PICC can be placed in either arm.
What are the advantages of a PICC?
• You do not have to go to theatre to have it inserted, this is done in the oncology day unit
• You do not need a surgical procedure to insert or remove it
• It keeps scarring to a minimum (only a small puncture scar)
• There is less risk of complication during insertion
What are the disadvantages of a PICC?
• The dressing needs to be changed once a week by a carer/ relative or nurse
• You cannot go swimming with a PICC and it may restrict you continuing with other vigorous sporting activities
How is the catheter inserted?
You will be laying on your back with your arm out to the side. A nurse or doctor will locate your vein using an ultrasound machine and then inject a local anaesthetic to remove the sensation from the skin over the vein. A tourniquet is applied to your upper arm. A small cannula or needle is inserted into the vein which is used to assist entry of the PICC into the vein. A slightly bigger plastic tube (an introducer) is inserted after this which will help with threading the PICC into the vein until the tip is in the correct position. The introducer is removed after this and only the PICC is left in position. A special device is clipped to the PICC to secure it in place on the skin.
An antimicrobial absorbent pad is placed around the PICC to reduce any bleeding which may occur in the first week and then covered by a transparent dressing. Confirmation of the correct position of the tip of the PICC will be done using a chest x-ray which you will go to the radiology department for.
How do I care for the PICC?
The dressing will only need to be changed once a week. This can be done by attending the hospital or by a district nurse or we can teach a relative or friend to do this for you when you are at home.
You should have a shower, or all over wash every day to keep your skin generally clean. The transparent dressing over the exit site is shower proof; however, take care not to get the PICC or extension set wet. The dressing must remain clean, dry and stuck firmly to your skin.
It is advisable to get a waterproof sleeve to wear in the shower to protect the PICC. You will have a securacath or grip lock dressing. The SecurAcath securing device keeps the PICC in place and does not require changing until the PICC is removed. The grip lock will get changed weekly. During the first week after your catheter has been inserted, the PICC site may become red and inflamed. Warmth, like a covered hot water bottle and resting the arm on a pillow, may relieve this. You can use warmth for the first 48 hours to reduce the likelihood of this happening. If it does not help, please contact the hospital.
How is the catheter removed?
Taking out a PICC is not a special procedure. It is like having a cannula removed. The nurse will place your arm on a pillow and remove the dressing. The nurse will gently remove the securing device and pull the PICC out of the vein. A dressing will then be applied to the site. Sometimes the securing device can be uncomfortable during removal. If it is uncomfortable, we can inject some local anaesthetic in the area. The dressing can be removed after 24 hours.
What is a skin-tunnelled catheter?
A skin-tunnelled catheter is a tube (sometimes called a Hickman line) which is inserted through your chest into a large vein leading to your heart. Along the catheter, there is a small cuff which you may be able to feel through your skin. This cuff prevents the catheter from moving or falling out. The catheter can be inserted on either side of your chest.
What are the advantages of a skin - tunnelled catheter?
It has a larger bore (internal diameter) than a PICC so viscous (thicker) IV therapies can be delivered faster. It can have one or two lumens. There is a Dacron® cuff which is tunnelled under your skin just above the exit site. In 3-4 weeks, tissue will grow onto this cuff and create a seal. The seal helps the catheter from slipping out.
What are the disadvantages of a skin-tunnelled catheter?
• You will need to go to the radiology suite or theatre to have the catheter inserted. This is carried out under local anaesthetic which is used to numb the areas where the catheter will be inserted.
• It requires a surgical procedure when removing it (but not in theatre).
• You will be left with three small scars – one over your collarbone and one where the catheter comes out of the skin. On removal, another small cut is needed to get the catheter out – about 5cm from the exit site.
• You cannot go swimming while you have a skin-tunnelled catheter but your other activities should not be restricted.
How is the catheter inserted?
You will be admitted to the oncology day unit for the day. The procedure will be done in the radiology intervention suite or in theatres. The inserter (anaesthetist or specialist practitioner) will insert the catheter after numbing an area on your chest with local anaesthetic.
Two small cuts will be made on your chest – one to tunnel the catheter and the other, above your collarbone, to insert it into your vein. You will have two small areas with stitches, one where each cut has been made. These take 10 – 14 days to absorb so do not require to be removed. During this time, it is recommended not to perform any vigorous sporting activities as the catheter could become dislodged.
After the catheter has been inserted, your shoulder and chest area (where catheter has been placed) may feel stiff and painful for a couple of days. You may find that painkillers help relieve the discomfort. We will take a chest x-ray to check that the catheter is in the right place.
How do I care for the skin tunnelled catheter?
This is the same care as for the PICC. The dressing will only need to be changed once a week. This can be done by attending the hospital or by a district nurse or we can teach a relative or friend to do this for you when you are at home. You should have a shower, bath, or all over wash every day to keep your skin generally clean. The transparent dressing over the exit site is shower proof; however, take care not to get the catheter or extension set wet. The dressing must remain clean, dry, and stuck firmly to your skin.
How is the catheter removed?
If you are on any anti-coagulants (blood thinning) drugs you will be asked to stop taking these a few days before the catheter is removed. Please seek advice from the nurse or doctor when the removal procedure is booked.
Usually, you will be admitted as a day case and will be in hospital for three to four hours. You may eat and drink on the day of the procedure as it is carried out under local anaesthetic on the unit. You will have a blood sample taken on admission or the day before to check your platelets, clotting rate, and haemoglobin. These checks are done to make sure that there is no risk of excessive bleeding during the procedure.
If these results are not satisfactory, it will not be safe to remove the catheter and you may be asked to return in a few days. We will also ask you if you have had any oozing, redness, swelling or pain at the exit site of the catheter.
Following satisfactory test results, the procedure will be carried out by a specially trained practitioner or doctor. It usually takes about 30 minutes. You will be asked to lie flat on the bed with one pillow. If you have difficulty lying flat, then please let the nursing staff know.
You may have felt a small lump under the skin where the catheter is, this is the cuff. If the lump is not visible, the nurse or doctor will check its location using a tape measure or ultrasound.
Local anaesthetic is then injected under the skin around the cuff. This will sting for a minute or two. When the area is numb, a small cut is made in the skin and the catheter is removed. You may feel a pulling and pushing sensation, but you are unlikely to feel pain However, if you do feel pain, let the practitioner or doctor know and they can give you more local anaesthetic.
Once the catheter has been taken out, the cut is stitched with two or three absorbable stitches and a dressing will be applied to the wound. We will ask you to continue lying flat for 30 minutes and if there is no further bleeding, you will be able to leave the hospital. You will be able to drive after the procedure.
If the wound bleeds within the first 24 hours, you will need to apply a further dressing over the original one. If the bleeding continues or you are concerned, then please telephone the unit. Further bleeding may result in a bruise, but this is normal.
If you have any pain following the removal of the catheter, you may take painkillers that you would normally take for a headache.
Following removal, you should:
• Avoid heavy lifting for the first 24 hours
• Avoid getting the stitches wet.
What is an implanted port?
An implanted port (sometimes called a ‘Portacath’) is a device which is inserted under the skin into your body. The usual position is on the chest or the upper arm. The port is made up of a portal body which is connected via a thin tube (catheter) and inserted into one of the veins.
The port can be felt through the skin. Entry to the port is gained by puncturing the silicone membrane with a special type of needle, which is attached to a length of tubing (an extension set). This will allow you to receive fluids and drugs or have blood samples taken from it.
Puncturing the port is like pricking the skin with a pin. Naturally it takes some getting used to. If it is painful, we can apply local anaesthetic gel to the area 30 minutes before we insert the needle to numb the skin.
What are the advantages of an implanted port?
• It only needs to have the needle put in when we need to use it
• The needle is removed in between treatments, and you will not have to worry about any dressings or flushing the catheter
• It does not restrict your normal activities including swimming
• It is completely hidden under your skin enabling you to wear any clothing without your catheter showing and prevent any accidental pulling out
• It can stay in for longer than a PICC or a skin tunnelled catheter.
What are the disadvantages of an implanted port?
• You need to have a needle inserted each time the port is used. The port can sometimes be difficult to access particularly within the first one to two weeks following insertion as the area is tender to touch
• It will leave some scars, if you are worried about scars then discuss this with the inserter to position the port to reduce scars, however the nurses may find it more difficult to gain access to it. As a result, you may find the needle access procedure more uncomfortable
• If you need to have blood tests, for example at your GP surgery or local hospital, you may find that the surgery staff are not trained to take blood from a port
• A port is not suitable for the infusion of stem cells.
How is the port inserted?
You will be admitted to the oncology day unit for the day. The procedure will be done in the radiology intervention suite or in theatres. The inserter (anaesthetist or specialist practitioner) will insert the catheter after numbing an area on your chest with local anaesthetic.
Two small cuts will be made. One to form a pocket for the port to sit in and the other, an entry site used to put the catheter through. The stitches over the pocket are dissolvable. We will take a chest x-ray to check that the port and catheter are in the right place. If you are requiring treatment the same day, we can insert the huber needle at time of insertion before returning to the oncology day unit.
How do I care for the port?
There is no special care needed for a port. The needle is removed in between treatments, and you will not have to worry about any dressings or flushing the port.
How is the port removed?
The port is removed surgically under local anaesthetic as a day case in the radiology intervention suite or theatres. You will be asked to stop any blood thinners.
In what circumstances should I contact Blackpool Teaching Hospitals or my local hospital?
Contact the hospital immediately if you notice any of the following:
• You develop a high temperature, fever, chills, or flu like symptoms (this could be an infection)
• Your arm, neck or shoulder is swollen and painful (this could be a sign of a blood clot)
• Your catheter is cracked or broken. In this instance fold or clamp the tubing above the crack or break in the tubing and tape it securely
• Your catheter is pulled out
• You think your catheter site looks red and inflamed, there is any discharge, or the redness is tracking up your arm from your PICC or PICC port – this could be early signs of infection
• Your PICC or Tunnelled line is leaking under the dressing
• Your PICC is partially pulled out (that is the length of exposed PICC is more than a certain number of centimetres. Your medical team will decide how much exposed length is safe for you and you will be informed afterwards). Do not attempt to push it back in
If you have any questions, please contact the staff caring for you.
Author Tessa Walmsley
Reference No PL/1560 (V1)
Review Date 01/02/2028
